How to cite this articleSilva NND, Chaves LN, Chaves LN, Rêgo AD, Araújo DB. Analysis of childbirth's aspects in adolescents and perinatal outcomes in a public maternity in the Amazon. Adolesc Saude. 2018;15(1):50-57

Abstract:OBJECTIVE: Evaluate and compare the frequency of childbirths betweeen adolescents and adult women, the possible associations between mother age and perinatal arrives (weight, gestational age and Apgar 5'), and delivery mode of childbirth occurred at Mulher Mãe Luzia Hospital in the city of Macapá - Amapá between January and December 2014. METHODS: A retrospective and cross-sectional study using Mulher Mãe Luzia Hospital´s deliveries database in 2014. The analyzed variables were: pregnancy age, delivery mode, Apgar 5' and birth weight. RESULTS: In 2014 occurred 7,762 deliveries, 2,254 being adolescents (29.04%), distribuited between 10 to 14 years old (8,03%) and 15 to 19 years (91,97%). It was noticed that premature delivery had bigger rates in the adolescents group, with higher index in the 10-14 years old subgroup (20.4%). Adolescents also presented higher percentageof low birth weight (11.1% against 8.6% in adult women), more concerning results in the group with 10-14 years (14.4%). Analyzing the Apgar 5'<7, it was noticed a minimal difference between the two groups (1.3% in adolescents and 1.2% in adults). CONCLUSION: The proportion of teenage pregnancy at Mulher Mãe Luzia Hospital was considered high in relation to the national average, noticing worse outcomes regarding premature birth, low birth weight and type of delivery, with a minimal difference in the variable Apgar 5'.

The World Health Organization considers adolescence the period corresponding to the age between 10 and 19 years, including pre-adolescence from 10 to 14 years. Thus, adolescence itself amounts to an interval between 15 and 19 years1.

Regarding teenage pregnancy rates, currently about 16 million women between the ages of 15 and 19 conceive a child each year, which corresponds to around 11% of all world Child-births, showing that one in each five girls become pregnant until they are 18 years old2.

Adolescent pregnancy is considered in some countries with a public health problem. It is known that it has negative effects in this age group, both for women's health and for their insertion in the labor market, reflecting their personal and professional growth3,4. As evidenced by the United Nations Population Fund (UNFPA) study, teenage pregnancies are highest in less developed countries, which in 2010 had an average of 103 Child-births per 1,000 women aged 15-19 years. This average is five times higher than that observed in the more developed regions, of 21 Child-births per 1000 women in the same age group5.

Important data to consider refer to the risk of maternal death among adolescents. According to a study by The Save the Children Foundation, in 2012 a risk of maternal death at 15 years was estimated at 395 per 100,000 live Child-births in developed countries and 667 per 100,000 live Child-births in developing countries6. Another point of great importance is the evolution of gestation among adolescents, where an increase in the incidence of prematurity, low birth weight, intrauterine growth restriction, intrapartum acute fetal distress, gestational diabetes, preeclampsia and incidence of cesarean sections. However, in relation to the type of Child-births, the literature is controversial about the prevalence of cesarean sections among adolescent pregnant women7,8,9.

According to national data, the occurrence of teenage pregnancy is still significant and has considerable rates in Macapá, probably related to the precariousness of family planning and sex education services. Given the scarcity of data in Amapá on this subject, it was observed the importance of analyzing the frequency and factors associated with teenage pregnancy in our country, so that, in this way, we know the magnitude of this problem, in order to guide strategies to prevent unwanted pregnancies in this age group and minimize their negative consequences on these adolescents. In view of all the repercussions that teenage pregnancy implies, this study aims to evaluate the frequency of pregnancy in adolescence in the Macapá - Amapá Public Maternity Hospital and its association with the occurrence of cesarean child-Child-births, prematurity, low birth weight, and Apgar score less than 7 in the fifth minute. In English, the word Apgar is an acronym referring to the parameters considered: A - activity (muscle tone); P - pulse (heart rate); G - Grimace (reflex irritability); A - appearance (skin coloration); R - respiration (respiration).

METHOD

A retrospective and cross-sectional study was carried out using the information from the Database belonging to the Medical and Statistical Archive Service (SAME) of the Mãe Luzia Women's Hospital (HMML) - a member of the Unified Health System - in the municipality of Macapá-AP. to the period from January to December 2014.

Mothers were divided by age group into three groups: adolescents aged 10 to 14 years, adolescents aged 15 to 19 years, and adults over the age of 19 years. The variables analyzed were: birth (vaginal or cesarean section), gestational age (greater than 37 or less / equal to 37 weeks), birth weight (considering low weight < 2500g and normal weight ≥ 2500g) and Apgar 7 in the fifth minute or greater / equal to 7 in the fifth minute).

Patients who had attended the HMML during the mentioned period were included in the analysis. The exclusion criteria were: parturients with multiple gestations, abortion (gestational age less than 22 weeks or birth weight less than 500 grams), stillbirths and incomplete birth records.

A total of 7762 child-Child-births were evaluated in one-year period, using descriptive and inferential statistical methods. Quantitative variables were presented by measures of central tendency and variation. The qualitative variables were presented by absolute and relative frequency distributions. The qualitative variables were compared using the Chi-square test. The quantitative variables were compared by Student's t-test. The significance level alpha = 0.05 was previously set for rejection of the null hypothesis. Statistical processing was performed in software GrafTable version 2.0 and Bioestat version 5.3.

The ethical concerns regarding the data extracted from the HMML database were based on obtaining the authorization for its use in epidemiological research in front of the data holding institutions, the Coordination of the Ethics and Research Committee (opinion No. 1.094.603) of the University Federal University of Amapá (UNIFAP) and the recommendations contained in the Nuremberg Code (1947), the Declaration of Helsinki (1964 and its revisions of 1975, 1983 and 1989) and Resolution No. 466 of 12 December 2012 of the National Commission of Research Ethics (CONEP) belonging to the National Health Council (CNS).

RESULTS

In the year 2014, 8323 child-Child-births were performed in the HMML, but due to the exclusion criteria, 80 cases of twin pregnancy, 16 cases of abortion, 140 cases of stillbirth and 325 cases due to incomplete data were disregarded. Of the 7,762 Child-births studied, 2,254 (29.04%) were women aged 10 to 19 years and 5,508 (70.96%) were 20 years or older (Table 1). The results are presented in tables with absolute and relative numbers and the mothers are grouped in adolescents and adults. The group of adolescents was subdivided into two groups, those with 10 to 14 years classified in pre-adolescents, with a mean age of 13.7 years and a frequency of Child-births of 8.03%, and those with 15 to 19 years classified in adolescents, with an average of 17.3 years and a childbirth rate of 91.97%. The mean age of the adults was 27.2 years.

Type of Child-Child-births

It was observed that the highest proportions of cesarean Child-births occurred in adult mothers (37.3%), with adolescent mothers having the highest proportion of vaginal child-Child-births (71.3%). Among the adolescents, the most submitted to cesarean sections were those aged between 15 and 19 (29%) (Table 2).

Gestational Age

It was observed that the highest rates of prematurity occurred in the adolescent age group (14.1%), while in adults the observed proportion was 12%. An even greater value (20.4%) was found in the subgroup of 10 to 14 years (Table 3). In the comparison between adolescents and adults, no statistical significance was observed (p-value = 0.54330).

Weight at birth

The proportion of newborns weighing less than 2500g and greater / equal to 2500g evaluated within each group showed a highly significant difference (Table 4). Adolescents presented a higher percentage of newborns with low birth weight (11.1%), while in adults, 8.6% (the comparison between these two groups didn´t show a statistically significant result). In the age group of 10 to 14 years the worst results were evidenced, with a greater number of newborns with low weight (14.4%).

Apgar score in the 5th minute

There was a highly significant trend in all age groups for Apgar from 7 or more, but in the comparison between adults and adolescents there was no real statistical difference (Table 5). Analyzing Apgar less than 7 in the fifth minute, there was a minimal difference between the adolescents (1.3%) and adults (1.2%), and the age group from 10 to 14 years old had slightly higher rates (1.8%).

DISCUSSION

Data published in the book of Sociodemographic and Health Indicators in Brazil10 showed a rate of 21.5% of Child-births in Brazilian adolescents in 2006. In that same year, in Amapá, the teenage pregnancy rate corresponded to 27.27%. At the time, the indexes of the state were only behind those verified for Tocantins (28.4%), Pará (29.3%) and Maranhão (29.5%). Observing these data, it is noted that the proportion of Child-births of adolescent mothers found in the present study for the year 2014 is considered high (29.04%). The percentage of Child-births performed in adolescents in the HMML (29.04%) was similar to those found in São Luis-MA (29.4%), but was above the rates observed in Montes Claros-MG with 21.5% and Campinas-SP with 17.8%12,13,14. Such studies corroborate the Sociodemographic and Health Indicators in Brazil that show higher rates of teenage pregnancy in the northern and northeastern states, and much lower rates in the South and Southeast10.

Analyzing the most recent data published by SINASC for the year 2013, a rate of 19.28% of child-Child-births in Brazilian adolescents, and of 25.84% in Amapá state11, is observed, with a drop in the national and thus increasing the discrepancy in relation to the number found in 2014 in HMML. As observed, the index found in this study (29.04%) was slightly higher than the average in the state of Amapá in 2013 (25.84%)11, which may be related to the fact that the present research was performed only in a public hospital where the low-income population is concentrated. This economic aspect may influence the lower attention during prenatal care, children with higher rates of low birth weight and neonatal and infant mortality, as well as social issues such as low schooling15.

Data from SINASC in 2013 show a proportion of cesarean child-Child-births of 56.63% in Brazil and 33.91% in Amapá11. Cesarean child-Child-births in the present study corresponded to 34.81% of the total number of child-Child-births analyzed, most of them in adult mothers (37.3%), a result similar to those obtained in national studies that identified a higher proportion of cesarean child-Child-births among adult women. Cunha et al. observed that advanced age represented a risk factor for cesarean section16. Martins et al. also add that this fact may be related to the high proportion of low birth weight infants among adolescents, facilitating their passage through the birth canal, which would favor vaginal birth in this age group17.

According to the Sociodemographic and Health Indicators: "The recommendation of the World Health Organization is for cesarean sections to be a maximum of 15% of total child-Child-births, limited to risk situations for both mother and child" 10. Considering the above, it is noted that in this study the rate of cesarean Child-births in both adolescent and adult mothers is well above those recommended by the WHO.

The higher prevalence of cesarean child-Child-births among adult mothers was also verified in other national studies such as the one performed in São Luís-MA; Campinas-SP and Montes Claros-MG12,13,14. Carniel et al. indicate that the chances for indication of these types of child-Child-births were higher in women with a higher socioeconomic level, in those with adequate prenatal care, in primiparous women, in multiparous women, and in double pregnancies14.

Analyzing the variable gestational age, it was observed that prematurity was higher among adolescent mothers than in adults, with a difference of 14.1% versus 12% (but not statistically significant), and this difference was even greater in the age group of 10 to 14 years old who presented a rate of 20.4% showing a relation between maternal biological immaturity and prematurity. Simões confirms this relationship by suggesting that biological factors linked to immaturity are associated with higher rates of low birth weight, prematurity and infant mortality12. The results obtained in the present study were similar to those found in Montes Claros-MG and São Luís-MA, where there were also more premature Child-births in adolescent mothers12,14.

In relation to the variable birth weight, there was no statistical significance, with higher rates of low birth weight in newborns of adolescent mothers, in a difference of 11.1% against 8.6% in adults, with higher rates of low birth weight in mothers aged 10 to 14 years (14.4%), a fact associated with prematurity. According to Amaya et al., Low birth weight is the most important factor associated with perinatal mortality and morbidity when evaluating the outcome of pregnancy, besides being the single most important indicator of infant morbidity and mortality18. In the literature, there are studies that show a higher frequency of low birth weight infants, especially in adolescents between 10 and 15 years of age, probably due to low maternal weight before pregnancy, insufficient weight gain, family and existential conflicts that delay the demand for care prenatal care, a higher incidence of anemia and infections, and incomplete development in the reproductive organs, which can lead to placental insufficiency, hindering maternal-fetal exchange19.

Regarding the Apgar score lower than 7 in the 5th minute, it was observed that there was not a big difference between the groups of adolescents (1.3%) and adults (1.2%). The greatest difference was observed in the age group of 10 to 14 years old that presented index of 1.8%. A similar study carried out in Montes Claros-MG also showed a variation according to maternal age, with an index of 2.9% among adults, 3.3% between 15 and 19 years and 6.0% in the 10 to 14 years. However, there is a need for more information to compare the studies, since the author13 correlated Apgar data with prenatal care, noting that among adolescents between 10 and 14 years of age with adequate prenatal care there was no case of neonatal asphyxia.

Ramos and Cuman point out that teenage pregnancy is the factor of higher concentration of maternal health problems, as well as perinatal complications such as low maternal weight gain, cephalopelvic disproportion, preeclampsia, prematurity, low birth weight and Apgar low in the fifth minute, which explains the poor obstetric results in adolescent mothers. However, they point out that the intercurrences related to adolescent pregnancy are potentialized when associated with socioeconomic and geographical conditions, as well as the fragility of the family structure and the difficulty of accessing care services, demonstrating that there is a multi-causal network associated with this problem20.

As stated, the social context in which young mothers are inserted implies unfavorable perinatal outcomes, and the issue of incomplete or incomplete prenatal care is an essential factor to be considered. Goldenberg et al. confirm this fact by stating that inadequate prenatal care confers a greater chance of prematurity and low birth weight13.

CONCLUSION

Much is said about the association between teenage pregnancy and perinatal outcomes. This study looked for the comparison analyzing the variables gestational age, birth weight and Apgar in the fifth minute, but it was noticed that several are the works that point to a complex and multivariate relation. Regarding the type of Child-births, this study showed a higher frequency of vaginal Child-births in adolescents than in adults, and the other variables studied (prematurity, low birth weight and Apgar less than 7 in the 5th minute) were not significantly different between the groups adolescents and adults, but when comparing the two groups of adolescents we observed worse results in adolescents between 10 and 14 years.

As previously pointed out, it is undeniable that the index of adolescent pregnancy recorded in this study (29.04%), even reflecting the reality of a single motherhood is high compared to the national average, is relevant since this is the only maternity the city of Macapá, where most of the Child-births subsidized by SUS in this state are performed. In view of all the consequences that pregnancy in adolescence imposes, it is necessary to apply public policies that promote the sexual education of young people with a view to their prevention. In addition, there is also a need for awareness campaigns on the importance of adequate prenatal care and methods of contraception that reach all phases of adolescence, not just the pregnant teenager.

Because teenage pregnancy is considered a public health problem, due to its negative consequences for pregnant women and newborns, it is important to apply preventive programs at basic health care level. As Yazlle (2009) suggests, this could be done through the training of medical professionals, nurses, those working in the area of Education, social work and psychology, as well as the support of governmental and nongovernmental entities present in the community that can contribute to a program for the prevention of teenage pregnancy and its repetition.